Sphincter Saving Procedures

The treatment for rectal cancer has changed fundamentally over the past ten to twenty years.

The general thrust of these changes have been toward a lesser invasive approach with preservation of intestinal continuity and the avoidance of the psychological sequalae of a stoma. Still, in the 1980s and 1990s, the majority of patients with carcinoma of the rectum underwent abdomino-perineal excision as proposed by EW Miles 1908 (excision of the entire rectum). For the patients, this resulted in a definitive loss of continence and the formation of an end colostomy sited in the left iliac fossa. The rationale of this radical and mutilating approach was that only by such a procedure could tumour relapse be safely avoided. Apart from these deficits in knowledge on tumour biology, the limited inhibit to insufficiently developed operative techniques further restricted the possibilities of restitution of intestinal continuity in the supra-anal region.

Furthermore, there have been significant improvements in radiation therapy, chemotherapy and surgical technique. The development of an inter-disciplinary approach to treatment has significantly increased the likelihood that a patient with rectal cancer may receive curative treatment with a preservation of continence. With the rediscovery of patho-anatomical and patho-physiological knowledge comprehensively layed out by Vesthus in the 1930s, a re-orientation process set in and led to new surgical concepts for the therapy of rectal cancer. The key factors supporting these new concepts are that an intra-mural tumour dissemination beyond 2cm toward the distal end of the rectum is extremely uncommon. Lymphatic drainage of the rectum, beginning at the levator level, primarily follows its central direction exclusively. Therefore, to avoid local recurrence safely margins are less determined in their distal direction than much more importantly the lateral spread.

Only a minority of rectal cancer patients (approximately 6%) require an abdomino-perineal amputation to obtain disease free distal and lateral resection margins. Similarly, operative techniques such as the colo-anal anastomosis with a colonic pouch or the application of circular linear staplers have been developed, allowing a safe anastomosis deep into the pelvis and on to the top of the anal canal.

What is Rectal Cancer & Sphincter Saving Procedures

Rectal cancer is a condition in which cancer cells form in the tissues of the rectum, which forms part of the body’s digestive system. Rectal cancer is divided into various stages, each with its own symptoms and degree of urgency. Stage 0 is when the tumour is located on the inner lining of the rectum, whereas stage IV is when the tumour has metastasised to other parts of the body.

There are many risk factors that may increase your chances of getting rectal cancer, which is why early detection is absolutely essential. Some of the risk factors include being over the age of 50, having a family member with a history of colorectal cancer, polyps or cancer of the breast or ovary, as well as having certain hereditary conditions such as HNPCC or Lynch syndrome.

If surgery needs to be performed, one of the most popular sphincter saving procedures is low anterior resection. This involves removing a part (or all) of the rectum and taking healthy bowel from the colon, and connecting it to the rectum. Another procedure that can be performed is a local excision, where the cancer is removed through the anus or tailbone area, without a colostomy. This procedure can sometimes be done in the outpatient area.

The recognition that the probability of lymphatic metastasis depends on the size and more so on the depth of invasion and the degree of differentiation of the tumour as it has made it feasible to treat selected tumours in the distal third of the rectum exclusively by local excision. In consequence, for the majority of rectal cancer patients, there is no advantage (in terms of local recurrence, recurrence of distal metastasis in five year survival) in performing abdomino-perineal resection instead of a sphincter preserving procedure. It is also important to note that anal incontinence can be affectively maintained with sphincter saving procedures.

Physiological aspects – reference surgery for cancer of the rectum

One of the key aspects in managing patients with rectal cancer concerns the physiological impact with the various forms of treatment. It is not clear whether a colostomy causes sexual dysfunction or whether disruption of the pelvic plexus is the underlying cause of this problem. Only a few studies compared post-operative psycho-social adjustment in ostomy patients with that of non-ostomy patients. In this context, we have to consider that when supra-radical lymphadenectomy for rectal cancer is performed, long-term difficulties in passage of urine seems to affect 1/3 of the patients, 20% seem to require long-term use of a urinary catheter and impotency is reported in 76% of patients under the age 60 years.

The message is that he quality of life; including sexual function in stoma patients is less than those with no stoma. Therefore, surgical strategies to overcome the need for a permanent stoma following major rectal surgery are mandatory.

Factors influencing sphincter and organ preservation in patients with rectal cancer can be described as follows;

Factors influencing sphincter preservation

Surgical training It has been widely shown that surgeons trained to perform oncological colorectal surgery achieve a much higher overall cure rate with a lower instance of local recurrence and less surgical morbidity.

Surgical volume It has been widely shown that surgeons performing TME on a regular basis, i.e twenty cases a year have a higher cure rate with less operative morbidity and a lower recurrence rate.

Neo-adjuvent chemo/radiotherapy

Factors associated with difficult sphincter preservation

Male sex

Morbid obesity

Pre-operative incontinence

Direct involvement of anal sphincter muscles with carcinoma

Bulky tumour within 5cm from the anal verge

Patient selection for local excision

Lesions located in the very rectum, i.e within 8 to 10cm

Lesions occupying less than 1/3 of the rectal circumferential

Mobile exophytic or polypoid lesions

Lesions less than 3cm in size

T1 lesions

Low grade tumour (well or moderately differentiated)

Negative nodal status (clinical and radiographic)

Disadvantages of APR

Need for a permanent colostomy

Significantly higher short term morbidity and mortality

Significantly higher long term morbidities

Higher rate of sexual and urinary dysfunction

As a specialist gastroenterologist, Dr Michael Elliot specialises in rectal cancer treatment and sphincter saving procedures. Based in Claremont, Dr Elliot performs all of his surgery at the Life Kingsbury Hospital Claremont. For more information about rectal cancer or sphincter saving procedures, please contact Dr Michael Elliot.